Provider Demographics
NPI:1790809531
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST NEUROLOGY - WESTCHESTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP NETWORK PHYS & HS CMO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARS
Authorized Official - Last Name:HOWERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-716-1331
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:1814 WESTCHESTER DR
Practice Address - Street 2:SUITE 401
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7299
Practice Address - Country:US
Practice Address - Phone:336-802-2080
Practice Address - Fax:336-802-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912993Medicaid
7656739OtherAETNA
NCCC4242OtherRR MEDICARE
269374OtherMAMSI
50102OtherMEDCOST
NC0218GOtherBCBS
NCCD6614OtherRR MEDICARE
NCCB8658OtherRRMC
NCD266OtherPARTNERS MEDICARE CHOICE
NC1212660031OtherMEDICARE DME
NCCC4243OtherRR MEDICARE
NCCC5472OtherRR MEDICARE
NCCC6608OtherRR MEDICARE
NC890218GMedicaid
NCCC4241OtherRR MEDICARE
NCCF9200OtherRR MEDICARE
NCCC5472OtherRR MEDICARE
NCCC4243OtherRR MEDICARE